Kidney Dialysis Foundation

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WHAT IS KIDNEY DISEASES
Kidney diseases are diseases of the kidney substance that alter the structure and function of the kidney. There are many diseases of the kidneys such as glomerulonephritis, pylonephritis, polycystic kidney, nephrotic syndrome and lupus nephritis. The treatment and potential for recovery depends on the type of disease. Kidney diseases can lead to the kidney failure.

WHAT ARE THE SIGNS AND SYMPTOMS OF KIDNEY DISEASES?
1. Burning sensation during urination.
2. A change in the frequency or pattern of urination.
3. Passing bloody or coffee-coloured urine.
4. Puffiness around eyes, swelling of hands, feet or abdomen.
5. Pain in the lower back area just below the rib cage.
6. High blood pressure.

If these symptoms are present, consult a doctor. Further investigations need to be carried out to find out the cause. It is possible that a person may not have these symptoms even though he/she is losing kidney function. The clue to kidney disease may be abnormal urine findings picked up on urine tests alone.

Diabetes is the most common cause of chronic kidney failure in Singapore. It accounts for up to 50% of new patient with end-stage kidney failure. Because there is no definite cure as yet for diabetes, prevention of kidney-related complications is crucial.

WHAT IS DIABETES MELLITUS?
Diabetes Mellitus, or simply called "diabetes" is a disease where the body is unable to make insulin or unable to utilise the insulin secreted from the pancreas properly resulting in glucose buildup in the blood. Insulin is a hormone that regulates the amount of sugar in the blood.

There are two types of Diabetes:

	Insulin Dependant Diabetes Mellitus (IDDM) or Type 1 Usually occurs in children, also known as "juvenile diabetes". The pancreas produces little or no insulin. People in this group require daily insulin injection.
	Non-Insulin Dependant Diabetes Mellitus (NIDDM) or Type 2 Usually occurs in persons over 40 years old, also known as "adult onset diabetes". The pancreas produces insulin but the body is unable to utilise it properly. Blood sugar can be controlled by diet and/or medicine, although some may require insulin.

How does diabetes affect your body?
Uncontrolled glucose level in the blood causes changes to and damages the blood vessels. This affects not only blood vessels in the kidneys, but also blood vessels in other organs such as the eyes, skin, nerves, intestines, muscles and the heart. Both large and small vessels are affected. It is common to find patients who have had longstanding diabetes requiring amputation of a leg because of insufficient blood supply and infection.

What does diabetes do to the kidneys?
In diabetic kidney disease, there is obvious involvement of the glomeruli. The glomerulus is a ball of blood vessels, which act as the filtering units in the kidney. Early involvement shows up as leakage of protein in the urine. In medical terms, this is called "proteinuria". As proteinuria becomes more severe, functions of the kidney such as balance of salt and water become deranged causing salt and water retention. The patient then will notice some weight gain and swelling especially in the face in the morning and legs at the later in the day. In more advanced stages, the kidney filters become totally destroyed leading to a state of kidney failure.

Diabetes may also damage nerves. There may be difficulty in emptying the bladder as this depends on intact reflexes from the nerves and coordination between nerve and muscles of the bladder. The pressure from an overfull bladder can 'push' urine backwards towards the kidneys causing injury. Urine remaining for a long time in the bladder because of incomplete emptying, can also cause a urine infection.

What are the signs of kidney disease in patients with diabetes?
Early stages of kidney involvement without kidney failure are characterised by

	Protein in urine
	High blood pressure
	Ankle and leg swelling
	Frequency of urination especially at night

When kidney failure sets in, other features become evident:

	Water retention becoming more resistant to medication
	Poor appetite, nausea and vomiting
	High level of urea and creatinine in blood
	Weakness and pallor from anaemia
	Itching

What can patients with diabetes do to prevent kidney damage?
The risk can be lowered by:

	Good control of diabetes by a combination of a diabetic diet and medication if necessary
	Good control of blood pressure
	Regular follow up to monitor if the control is adequate

If kidney involvement has already been diagnosed, does this mean one has kidney failure?
No, kidney function is normal at first. It takes a few years before early involvement leads to kidney failure. While there is no cure, there is time to slow down the process with treatment.

What specific measures can be taken to retard the progression to kidney failure if the kidney function is still normal?
Diet
Continue with your special diabetic diet as before. Further dietary modification may be necessary especially with respect to salt, amount of fluid consumed and potassium.

Your doctor will advise you on your fluid allowance and diet restriction. The dietitian will help you to plan your diet according to the stages or severity of the disease process.

Medications
Anti-hypertensive medications are often needed for blood pressure control. Angiotensin converting enzyme inhibitors (ACE inhibitors) and Angiotensin receptor blockers (ARB) are special categories of anti-hypertensive medications that can reduce protein leakage.

Diuretics may be added to encourage more urine production to control fluid retention.

Close monitoring of the sugar level is necessary and this often leads to adjustment of the dosage or change of anti-diabetic medicine to maintain good control of sugar levels.

Will dialysis be needed if the diabetic patient starts to have kidney failure?
No dialysis is required in early kidney failure. It will be needed in advanced kidney failure when the state of "end stage kidney failure" is reached. Generally, it means that the kidneys are functioning at less than 10% of its original capacity. The progression of kidney failure from its early stage to advanced stage can be retarded with drugs and proper dietary restriction so it is important that diabetic patients maintain close follow up with their doctors.

If dialysis is deemed by your doctor to be required soon, you should also discuss with him the option of a kidney transplant instead of long-term dialysis treatment.

Glomerulonephritis is second most common cause of kidney disease in Singapore, the first being diabetes mellitus. mellitus.

What is glomerulonephritis?
Glomerulonephritis means inflammation and scarring of the kidney filters. There are different types of glomerulonephritis. Infections by bacteria, virus and parasite can cause glomerulonephritis through its effect on the immune system. Autoimmune diseases such as systemic lupus erythematosus (SLE) and IgA Nephropathy are other types of glomerulonephritis. In Singapore, IgA Nephropathy is the most common form of primary glomerulonephritis.

How does glomerulonephritis come about?
When a person has infection or autoimmune disease, the fighter cells in the body react to cause antigen and antibody complexes to form in the blood stream. When the blood with these complexes reaches the kidney filters (glomeruli), the filters become inflammed and scarred from the insult. In severe cases, kidney filters die and the ability of the kidney to remove the extra waste products and water decreases.

- How are these antigen and antibody complexes formed?

Antibodies are made by the body in an attempt to eliminate foreign matter (antigen). An antibody is an agent, which can attach to an antigen that it is trying to destroy, thus forming antigen and antibody complexes. When the immune system is over-reactive, abnormal antibodies or abnormally high levels of antibodies are produced. Other problems include an inability of the body to clear these complexes from the blood stream. In many types of glomerulonephritis, the antigen is often not known. Occasionally the antigen is the body's own tissues or even the kidney itself. It is often not clear why these complexes form.

What are the signs and symptoms of glomerulonephritis?
Glomerulonephritis usually has no signs and symptoms until the kidney filters are damaged. Therefore, if the disease is in an early stage, it is usually detected following pre-employment or life insurance screening as presence of blood or protein in the urine and in Singapore, when young men sign up for their National Service, they have to go through a routine medical examination including a urine examination.Some other types of glomerulonephritis are associated with skin or joint disorders and may be detected when patients seek treatment for their joint or skin problems.

When the kidneys are severely damaged, a person may present with complaints related to kidney failure, which include:

	Headache, nausea, vomiting, fever, chills.
	Less urine output because of reduced urine production.
	Swelling especially in the face, hands and feet (edema) due to water and salt retention.
	High blood pressure which is > 130/80 mmHg (Hypertension).

What investigations are performed to identify glomerulonephritis?

	Urine sample to check for presence of blood and protein.
	24 hours urine collection and blood sample to check for level of creatinine in the blood stream and urine to assess kidney function and amount of protein passed out.
	Swelling especially in the face, hands and feet (edema) due to water and salt retention.
	A renal biopsy (a tissue taken from the kidney) to determine the type of kidney disease. It is usually done when the disease is more advanced and more specific treatment options need to be considered.

What is the long term outlook for patients with glomerulonephritis?
It depends on various individuals with different types of glomerulonephritis and different signs and symptoms. Those patients who have only blood in urine with no significant protein leakage from the kidneys may resolve and get well.

However, those with large amount of protein in the urine or if the renal biopsy shows damage of kidney filters, is likely with time develop kidney failure. So far, there's no means of preventing glomerulonephritis.

If the person has been diagnosed with glomerulonephritis, what can be done?
Often there is no cure for chronic glomerulonephritis. However, the inflammation can be controlled and progression of damage to the kidneys can be slowed down.

What are the types of treatment available to slow down the progression of damage to the kidneys?
In a very mild case, no treatment is necessary. Your doctor will let you know what stage of glomerulonephritis you have.

For moderate and advanced cases treatment includes:

Drug therapyrapy
	Treatment of high blood pressure with antihypertensives reduces stress to the kidney filters.
	If there is fluid retention, diuretics will help to get rid of the excess water and salt. The drug causes a lot of urine to be passed out.
	Reduce the leakage of protein with certain classes of anti - hypertensives called ACE inhibitors or Angiotensin II receptor blockers. These drugs reduce the leakage of protein into urine.
	Anti-platelets (dipyridamole) and anti-coagulant (warfarin) have been shown to be effective in IgA Nephropathy.
Dietary measuress
	Control salt and water to prevent fluid retention.
	Control potassium to prevent abnormal heart rhythm .
	Control protein intake to reduce stress to the kidneys. There is a very fine balance between too much protein, which can stress the kidney, and taking too little, which can lead to malnutrition. It is very important that you see the dietician so that she can assess and advice you on the correct amount to take.

When will a patient with glomerulonephritis have kidney failure?
The time it takes for a glomerulonephritis to cause kidney failure is usually many years. Because there are often no symptoms, many people do not know they have glomerulonephritis. Even when tested positive for urinary abnormalities this is ignored as there is often no pain or swelling seen. A mild case in which no treatment is required can progress to a more serious stage requiring treatment. Those on treatment may default because the patient feels well. The opportunity to control the illness is then missed because when symptoms surface the patient may already have kidney failure.

What are some points to remember if one is diagnosed with glomerulonephritis?
It is therefore important to remember the following points:

	a)	Mild Cases Even if there is no treatment, monitoring on a yearly basis is necessary with your family doctor. If the urine protein becomes excessively high, you should come back to the hospital for further assessment.
	b)	Moderate to advanced cases Medication would usually have been started. Follow up should continue and monitoring of the degree of protein leakage, kidney function and complication of the drug Treatment should be done periodically. Prevention of kidney failure is the goal, as treatment of advanced kidney failure is time consuming and very expensive.

Remember, the whole process occurs over a long period of time, thus follow up and compliance to treatment is essential in preventing kidney failure.

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